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The clinical case formulation should involve a careful clinical history and summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. The case formulation is the clinician's interpretation of the patient's symptoms, overt behaviors, and covert personality dynamics framed within the context of social, cultural, physiological, and environmental influences. The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual's cultural and social context.

 

The symptoms in the DxP diagnostic criteria are a limited collection of human behavioral responses to internal and external stresses that are generally maintained in a homeostatic balance without a disruption in normal functioning. It requires clinical training to recognize when the combination of these factors has resulted in a psychopathological condition. The relative severity and weight of individual criteria and their contribution to a diagnosis require clinical judgment. Though it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis, a systematic check for the presence of these criteria as they apply to each patient will assure more accurate and reliable diagnoses.

 

In the DxP each diagnosis is accompanied by an automated recording procedure of the diagnosis name and ICD-10-CM. The program strives to follow the recording procedure outlined in the DSM-5. However, due to technical difficulty to emulate the dynamic flow of the diagnostic process, at times the program fails to produce the accurate name of complex diagnoses. In such cases, the clinician should use the “edit diagnosis free-text form” to correct such programmatic limitations.

 

The ICD-10-CM code is typically used by institutions and agencies for data collection and billing purposes. There are specific recording protocols for these diagnostic codes that were established by WHO, the U.S. Centers for Medicare and Medicaid Ser­vices (CMS), and the Centers for Disease Control and Prevention's National Center for Health Statistics to ensure consistent international recording of prevalence and mortality rates for identified health conditions. For most clinicians, the codes are used to identify the diagnosis or consultation reasons CMS and private insurance service claims. There are several online programs for converting between different mental health coding systems.